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Full text of "United States Navy Medical News Letter Vol. 44 No. 5, 4 September 1964"

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Vol. 44 



Friday, 4 September 1964 



No. 5 



TABLE OF CONTENTS 



MEDICAL, ABSTRACTS 

Combat Psychiatry in the Field 

Injuries of the Central Nervous 

System 



.3 
10 



MISCELLANY 

Applications for In service 
Residency Training 
1965-1966 

The Importance of Thorough 
Histories and Physicals Dur- 
ing Enlistment Procedures . . 

Physical Defects in Recruits . . . 

Freedoms Foundation Offers 
Honor Awards 

Annual Physical Examination of 
Inactive Naval and Marine 
Reserve Officers 



14 



14 
15 

19 



19 



FROM THE NOTE BOOK 

Dr. Benoit Sets Good Example 
of Authorship 

American Board Certifications . 

CNO's Message on President's 
Economy Program 

A New Smallpox Drug 



.20 
20 

.21 
.21 



DENTAL SECTION 

Dental Abnormalities in Rats 
Due to Protein Deficiency 
During Reproduction 22 

Effect of Sodium Monofluoro- 
phosphate Solution on Caries 
in Children 22 

Communications and Health 

Education 23 

Personnel and Professional 

Notes 24 

OCCUPATIONAL MEDICINE 

Houston to Host Occupational 

Health Congress 27 

Glue -Sniffing. 28 

Intertrigo and Heat Rash 31 

Studies in Ecology of Coronary 

Heart Disease 33 

Hazards May Lurk in Your 

Hobby 36 

RESERVE SECTION 

Farewell Remarks by RADM 
F. J. Becton-Give the ROA 
Your Support 39 



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United States Navy 
MEDICAL NEWS LETTEfi 



Vol. 44 



Friday, 4 September 1964 



No. 5 



Rear Admiral Edward C. Kenney MC USN 
Surgeon General 
Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine .CDR N. E. Roaenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine jCDR J. H. Schulte MC USN 

Reserve Section. .Captain K. W. Schenck MC USNR 

Submarine Medicine .CDR J. H. Schulte MC USN 



Policy 

The U. S, Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter to: Commanding Offi- 
cer, U. S. Naval Medical School, National Naval Medical Center, Bethesda, 
Maryland 20014, giving full name, rank, corps, and old and new addresses. 



The issuance of this publication approved by the Secretary of the Navy on 
4 May 1964. 



I 

U. S. Navy Medical News Letter, Vol. 44, No. 5 3 

Combat Psychiatry in. the Field 

CAPT C. S. Mullin MC USN, Chief of Neuropsychiatry Service, U. S. 

Naval Hospital, NNMC, Bethesda, Md. 

Future combat operations involving marine and naval units will undoubtedly 
differ radically from traditional methods and conditions of warfare of the past. 
The great sea and air battles of World War II and the mass infantry engage- 
ments of the Marines in the Pacific conflict and in Korea represent a kind of 
combat operation that is now of historical interest. But there is a continuing 
possibility that our forces will from time to time become involved in small 
"guerilla" actions, "brush-fire wars, " "police action, "and even operations 
involving the tactical use of atomic weaponry. However, regardless of the 
"style"of combat the response of a soldier or sailor to the dangers and dev- 
astations of war remains unchanging. Fear, guilt, and grief will continue to 
assault the sensibilities of the participants and give rise to the combat in- 
effective known as the psychiatric casualty. There is little reason to believe 
that the loss of effective fighting manpower from psychiatric causes will not 
continue to be of formidable concern. 

Frequency . During Army land operations in World War II the ratio of 
wounded in action to psychiatric casualties was frequently of the order of 4 
to 1. During the Korean conflict the ratio of Marines wounded in action to psy- 
chiatric casualties identified and recorded as such was of the order of 8 to 1 
although some engaged elements of the First Marine Division were far less 
affected by this source of manpower loss than others. Much depended upon 
the esprit of the unit and a number of other variables including the duration 
and intensity of the combat experience. 

The "Symptomatic" Picture . What does the combat induced psychiatric 
casualty look like after the first few days or weeks that he bears the label of 
combat fatigue? Several fairly distinct categories can be delineated. 

1. The Anxiety Eeaction . This term characterizes a response manifested by 
extreme apprehensiveness, tremulousness, marked autonomic overactivity, 
"startability, " hyperalertness, preoccupation with harrowing memories 
of battle experience, and catastrophic dreams. 

2. The Depressed Reaction. Here the depressive affect is associated with 
morbid preoccupation with combat experiences, and/or feelings of bereave- 
ment. Here grief and guilt are more obtrusive factors than the anxiety 
element which however is usually also present. 

3. The Apathetic Reaction. Here the casualty is withdrawn, more or less un- 
responsive, shows varying degrees of psychomotor retardation and is more 
or less unaware of surroundings. This may represent a defensive process 
of psychological retreat. When extreme this response may at times suggest 
catatonia. 

4. The Pseudo-psychotic Reaction. This may be manifested, by states of wild 
excitement, agitation, and disorganization; more or less obliviousness to 



4 U. S. Navy Medical News Letter, Vol. 44, No. 5 

the immediate environment, and a "running amok" picture. If the casualty 
is armed he can be dangerous because of the usually violent content of the 
dissociative condition in which the man behaves as if he were still in the 
combat situation and "trigger ready" to defend or attack without discrimi- 
nation as to friend or foe. 

5. "Hysterical" Reactions. Here the anxiety is "bound" by such gross symp- 
toms as blindness, deafness, dumbness, monoplegias, paraplegia, astasia- 
abasias, episodes of apparent unconsciousness, amnesia, etc. 

6. "Psy chosomatic" Reactions . These may include headaches, vertigo, synco- 
pal manifestations, vomiting, diarrhea, frequency of micturition, "effort 
syndrome" or other cardiovascular and respiratory manifestations. Where 
these psychosomatic manifestations are the obtrusive aspect of the picture, 
there is a real possibility of erroneous diagnosis and premature evacuation. 
If or when tactical atomic weapons are in use perhaps one can expect to 
see symptoms which reflect the man's own ideas of the manifestations of 
radiation sickness. 

The Term "Combat Fatigue". As a practical matter the term "combat fatigue" 
should be the initial diagnostic designation of all acute psychiatric conditions 
related to the stress of combat irrespective of the presenting symptomatic 
and behavior picture. In the combat situation there is good reason for avoiding 
diagnostic terms such as anxiety state, neurosis, psychosis, catatonia, blast 
concussion, hysteria, exhaustion, and the various designations commonly ap- 
plied to psychosomatic disorders. The majority of these acute conditions will 
be fluid, often changing rapidly in character and severity and to a more or 
less degree transient, even though the disturbance of behavior initially may 
be extreme. The use of these specialized terms is likely to lead to an assump- 
tion on the part of the patient that a greater degree of disability exists than 
is actually the case, as well as an assumption on the part of those handling the 
casualty that the very specialized forms of treatment or distant evacuation 
are required when in fact such indications may be absent. 

Etiological Factors. What are the major affective factors relevant to 
the development of combat fatigue? Fear is of course paramountjfear of death, 
of mutilation or of fear itself. In addition the man may have to deal with more 
or less rational responses of hate, resentment, guilt and griefjhate stimulated 
by the combat situation, grief for slain buddies and guilt that he has not per- 
formed manfully or that he has survived when others have not. Whether or not 
and how well a man stands up under these pressures of fear, hate, guilt, and 
grief depend upon a wide variety of interacting factors that might best be dis- 
cussed under the headings of (1) personal factors and (2) external circum- 
stances. Personal factors include the following: 

a. The quantum of anxiety ordinarily aroused in the individual by exposure to 
danger. The intensity of response to danger is of course the product of a 
man's inheritance, (i. e. , "constitution"), his experiences of, and responses 



U.S. Navy Medical News Letter, Vol. 44, No. 5 5 

to, danger situations in the past, especially in childhood, i. e. , what the 
threat of combat danger means in his personal psychological economy. 

b. His capacity for coping with the emotions of fear, by such defenses as 
pride and detachment, feelings of invulnerability, "self discipline, " con- 
fidence in his technical competence in his combat job, religious attitudes. 

c. His capacity for identification with the group. This is all important and 
will be mentioned more fully later, but the fact remains that there are in- 
dividuals who are deficient in the ability to feel a part of any group. This 
represents a handicap with respect to the ability to resist the effects of 
fear. 

d. Extra-military preoccupation; for example, concern about home, wife, 
children, parents, financial problems which may distract from and attenu- 
ate the strengthening bond he feels with the group. 

e. The presence or absence of such factors as physical fatigue, illness, and 
loss of sleep. All these conditions render the individual more vulnerable 
to impact of combat aroused emotions. 

External circumstances bearing on susceptibility to combat fatigue will in- 
clude the following: 

a. Whether or not the man has a strong and worthy group with which to iden- 
tify, whether it be a squadron, platoon, company, battalion, or ship. This 
identification is of enormous importance in protecting against undue anxiety 
and in assuring combat effectiveness. Feeling an integral and accepted 
part of the group is of importance because: The man believes this good 
and powerful group will protect him; because he loves the group he will 
therefore be willing to endure more;because if he dies a part of him lives 
on with the group. 

b. Identification with a worthy cause. The Russians at Stalingrad were fighting 
for their homeland, their cities and their families in a very immediate 
sense. The Americans in Korea, for example, did not often fully understand 
what they were fighting for. 

c. The military situation. This is of importance in determining the amount 
of stress the individual or group must bear. There is obviously less stress 
when the military operationis progressing well than when itis faring poorly. 

d. Duration of stress. It is by no means necessarily true that the longer a 
man remains in combat the less anxiety he experiences and the more ad- 
justed and effective he becomes. At least so far as land warfare is con- 
cerned, after an initial acclimatization a point of diminishing return sets 
in. 

e. Other external factors affecting the man's ability to withstand combat stress 
will include climate, terrain, loss of buddies because of casualties, dis- 
appointment in rotational expectancies, poor communications, permitting 
the development of anxiety -fraught rumors and psychological techniques 
of the enemy including leaflet dropping, seductive loudspeaker messages, 
the bagpipes of El Alamein, the banzai screams of the Japs and the night 
attacks (with bugles blowing) of the Chinese in Korea. 



6 U. S. Navy Medical News Letter, Vol. 44, No. 5 

Treatment and Disposition. The following are time tested basic principles of 
handling acute combat psychiatric cases: 

1. Treat the casualty as near the central area of operations as feasible. The 
farther removed the man is from the area of danger, other things being 
equal, the more likely his symptoms are to solidify. 

2. Endeavor to convey the idea that he is accepted as an honorable casualty 
of battle. 

3. Say or do nothing to arouse the hope that he might be evacuated unless you 
are certain that the cause is lost. 

4. Encourage, but do not press the man to talk about his experiences, to venti- 
late his feelings of fear, guilt, grief, and hostility. 

5. Sedate sufficiently to assure several hours of sound sleep. 

6. Return to duty as expeditiously as possible. 

Who to Evacuate for Specialist Attention. The following are guidelines: 

1. The obviously psychotic. (This does not necessarily include the "beserk" 
or the pseudo-psychotic as described above but those who are clearly 
schizophrenic, manic or profoundly depressed and retarded. Typical psy- 
choses are extraordinarily rare in combat). 

2. The hysteric. The patient with gross hysterical symptoms as blindness, 
deafness, paralysis, etc. .which is not the result of exposure toanearby 
explosion and are obviously associated with a fragile immature personality. 

3. The severely apathetic and retarded type of casualty who appears totally 
depleted emotionally (but care should be taken to assess the importance of 
sheer physical fatigue and sleep loss). 

4. The man who has repeatedly panicked. 

5. Gross chronic tremulousness associated with gross chronic startability. 

6. The NCO (or officer) whose symptoms, while not in themselves striking 
or severe, imply significantly impaired judgment or unacceptable example. 
However in determining who should be retained for speedy return to duty 
and whom to refer for specialized attention, considerations other than the 
presenting symptomatology must be reviewed. 

These include the following: 

1. Previous combat performance. If this has been good the prognosis is likely 
to be more favorable. 

2. Maturity and emotional stability of a man's "previous" personality as far 
as this can be ascertained. 

3. The degree of improvement shown after the first day or two of medical at- 
tention. If properly treated, improvement in most cases should be quite 
rapid. 

4. The elusive quality known as personal motivation. Men with relative obtru- 
sive symptoms and high grade motivation can be returned. Men withlesser 
symptoms and markedly deficient motivation must frequently be evacuated. 

Clinical Example. The principles of treatment and disposition of combat 
fatigue cases might best be illustrated by describing how a number of severely 
disturbed patients were handled by the author one night in Korea in May of 1951. 



U.S. Navy Medical News Letter, Vol. 44, No. 5 7 

Nineteen casualties were admitted during the course of the night. These 19 
were members of two companies of the attacking forces that were pinned down 
for two hours by devastating mortar fire with severe casualties. They were ad- 
mitted to the care of the forward combat fatigue unit within an hour of their 
relief. Almost to a man they were severely "shook. " Some were ina dissoci- 
ated state, reliving their experience noisily and with hallucinatory vividness. 
Some were weeping without restraint. Others sat striken and immobile staring 
into space. 

The first thing was to isolate those patients whose behavior was quite 
disturbing to the rest of the group. We {my corpsmen and myself) moved about 
among the rest of the group taking a two or three line history, offering as 
much solace and comfort as we could. For those who wanted it and could take 
it, hot soup was made available. All were sedated quickly according to their 
apparent needs (with combinations of nembutal and sodium amytal). We were 
not sparing with our sedation. Our feeling was this first night was of vital im- 
portance and we should aim at the elimination of anxiety -producing stimuli 
either from without, i. e.., the sound of battle in the distance or the noise of 
the camp, or from within, i.e., the man's own memories of his harrowing 
experiences. My corpsmen assistants and myself spelled one another, staying 
with the group throughout the night giving additional sedation or word of com- 
fort and reassurance when indicated. We permitted the men to sleep as late 
as desired the following day. 

In the afternoon we went about talking with the men, sometimes in a 
group, sometimes individually, endeavoring to create the impression they 
were considered honorable casualties of battle, that there was nothing unusual 
about their condition and that their symptoms were not evidence of weakness 
of character. In one or two instances where we felt that an emotional explosion 
was imminent we removed the man to our interview tent and encouraged him 
to talk out his experience. The aim was twofold; first to permit the man to 
ventilate his feelings, and secondly to avert the possibility of a disturbing dis- 
play in the presence of the group. We arranged to quarter two or three ambu- 
latory wound cases who seemed suitable personalities in our NP tent explaining 
to them beforehand the reason. We felt that the presence of these relatively 
normal, relatively cheerful personalities would be helpful in dispelling the 
atmosphere of anxiety, gloom and failure that, to a more or less degree, 
pervaded the group. One of the casualties was an officer. His recovery was 
the most rapid. He was apparently a highly respected leader. We took advant- 
age of his influence and encouraged him to go among the men talking with them 
individually and collectively. For those who felt up to it we provided shaving 
equipment, some card games and writing materials. We again sedated most 
of them the second night but considerably less heavily than the night of ad- 
mission. Again either myself or my corpsmen stayed with the group. 

The following morning we required all of these men to be up at reveille, 
police their area and obtain their food from the chow line. Following chow we 
persuaded all of them out of their tent and tried to interest them in volleyball 



8 U. S. Navy Medical News Letter, Vol. 44, No. 5 

andhorae-shoes. They were for the most part still somewhat shaken and still 
obviously somewhat preoccupied by their experiences but still there had been 
remarkable improvement. At this juncture of the treatment we deliberately 
turned from the initial attitude of unqualified support for their regressed needs 
to the encouragement of self-determination and initiative. Nothing was said 
either about evacuation or about return to duty. We interviewed a few men in- 
dividually who seemed to have particular problems with respect to guilt in 
hopes of alleviating this but in the main, as always, our principal effort was 
directed to the group. 

On the third night most of them slept pretty well with minimum seda- 
tion. On the fourth day we conducted a formal sick call and announced to all 
but 2 or 3 men (of whom we felt quite unsure) that a duty party was forming 
and how about going along. We spoke to each man in such a way that his reply 
could be heard by the others. It may seem rather calculated to take advantage 
of a man's pride and concern about the opinion of his fellow Marines in this 
fashion but this approach spared the many fruitless arguments and psycholog- 
ically subversive resentments that so often ensued when the casualty was in- 
formed privately that he was to be returned to duty. Three of the original 19 
were evacuated;2 were retained foralittle longer and assigned to non-combat 
duties from the division; the remaining 14 were returned to full combat duty. 
None were readmitted as psychiatric casualties, at least, during the next 4 
months that I remained with the division. 

Prevention. The recognition and prevention of psychiatric casualties 
in battle is, in a broad sense, the responsibility of all officers, NCOs and 
corpsmen who have anything to do with the combat unit. The leadership quali- 
ties of the command are of crucial importance. It has been clearly demon- 
strated many times that there is a striking relationship between the incidence 
of combat fatigue and the esprit of the combat unit. While the quality of the 
line officer's leadership is of more central significance, the medical officer's 
contribution can be considerable. The battalion medical officer, for example, 
or the medical officer whose assignment places him in the position of the 
closest contact and intimacy with the combat group has a particular oppor- 
tunity and responsibility. He and the corpsmen he has trained are generally 
the first to receive and evaluate the emotionally disturbed man. How he 
evaluates, treats, disposes of the shaken marine or sailor is of the utmost 
importance in terms of the vital necessity of treating the manas soon as his 
symptoms become overt and returning him to duty as expeditiously as possible 
in all those cases where the man's condition or the facts of the military situ- 
ation do not require some form of evacuation. This (generally junior) medical 
officer who is most proximate to the combat involved element is in a more 
favorable and influential position with respect to effective handling of the com- 
bat fatigue case than any other medical officer within the combat organization 
structure. He lives more or less the same life and knows the stresses; he is 
generally an accepted member of the outfit; he is close to the sources of in- 
formation about the men. 



U.S. Navy Medical News Letter, Vol. 44, No. 5 9 

Points of Emphasis for the Combat Medical O ffi c e r 

1. Handle and treat as many combat cases as you can yourself. Send to the 
psychiatrist only the doubtful cases or those who have unequivocally lost 
their effectiveness in the foreseeable future; or those who cannot be held 
because of the tactical or logistical situation. 

2. Realize that sooner or later in a combat situation most men develop symp- 
toms of anxiety which will be present even when danger is absent. These 
would be palpitations, anorexia, gastric distress, frequency of micturition, 
diarrhea, ready startability, tremors, insomnia, headaches, irritability, 
mild depression or whatnot. These symptoms are not in themselves suf- 
ficient indications for relief from duty or for evacuation. 

3. And (as a correlary to the above) learn to recognize the various psycho- 
somatic aliases that may conceal the true genesis of the condition. 

4. Know the difference between true blast concussion and anxiety state. (The 
great majority of men initially diagnosed as suffering from blast concussion 
in the First Marine Division in Korea in 1951 were actually suffering pri- 
marily from an anxiety state re: a form of "combat fatigue"). 

5. Indoctrinate your corpsmen regarding the facts of life of combat fatigue 
so they can provide you with useful information and avoid sabotaging your 
efforts to get your casualties back to duty. 

6. Establish good working and social relationships with the "line" so that 
there may be an understanding of what you are trying to do; so that tney 
may provide you with the kind of information that is useful in understanding 
your man; so that they do not "use" you to dispose of disciplinary casesjso 
that they understand why you are holding combat fatigue: cases instead of 
evacuating them; so that they understand the importance of the behavior 
and attitude of the NCOs and officers in relation to the whole problem of 
combat fatigue. 

7. Keep informed about the tactical situation for the following reasons: 

a. In order to evaluate the degree of stress to which your man has been 
exposed. 

b. In order to understand conditions to which he may be returning. 

c. So that you will know how much time you have to hold and treat. 

8. Recognize the somewhat difficult truth that most of the shaken men sent to 
you off the line can return to duty andean function effectively and persevere 
better than you imagined when you first observed their distraught and often 
pleading condition. 

9. Finally, watch your own emotional state which may indeed prejudice your 
judgment, either because you are overidentifying with the combat fatigue 
case and unwisely recommending evacuation (by far the commonest error) 
or because you have developed a tired, irritable and resentful attitude that 
sends the wrong man back to danger or sends him back with the added bur- 
den of angry feelings because of your callousness and inhumanity. 

NOTE: It is strongly recommended that this excellent and highly practical 
paper of Doctor Mullin be reproduced at local levels and used as hand- 
out material to all personnel assigned to Surgical Teams, Casualty 



10 U.S. Navy Medical News Letter, Vol. 44, No. 5 

Evacuation Teams, and all Medical Department members serving (in 
anycapacity) for augmentation of FleetMarine and Amphibious Forces. 
It would also be well to consider a copy for each MC, MSC, DC, and 
NC officer reporting for first ACDU. -Editor 

# * * * * * 
Injuries of the Central Nervous System 

LCDR M. G. Andersen MC USN*. From the Proceedings of the Monthly 
Staff Conferences of the U. S. Naval Hospital, NNMC, Bethesda, Md. , 
1963-1964. 

In reviewing the topic of central nervous system trauma, we do not bring in 
statistical surveys or profound new discoveries, but rather discuss some of 
the more common conditions we may well see in the Emergency Room or where 
traumatic cases may be handled. Since our group is composed of military phy- 
sicians, our aims should be the improvement of our ability to diagnose and 

treat all forms of trauma. 

In line with this discussion, two incidents which occurred some years 
ago show opposite actions by Emergency Room medical doctors. The first oc- 
curred in an Emergency Room just as a patient was wheeled in. The doctor on 
duty, learning that it was an automobile accident case, called to the nurse, re- 
questing that a neurosurgical resident be called. The problem was a broken 
leg. The second case occurring in an Emergency Room did not have so good 
an outcome. In passing through the Emergency Room, the neurosurgical phy- 
sician saw a patient on a stretcher who needed neurological care. He was 
hemiparetip and semi-comatose. The patient had been lying there for some 
time waiting for the Emergency Room doctor to arrange for x-rays to be taken 
of his skull. However, because of his condition, the patient was immediately 
routed by the neurosurgeon to the Operating Room for evacuation of an epidural 
hematoma, and, although he lived, the follow-up on the patient revealed that he 

was mentally retarded. 

In order to avoid these two extremes, the following guide lines are 
suggested* Instead of dividing injuries into concussion, contusion, laceration 
of brain, and so on, we should consider the problem under three different cat- 
egories^ 1) Cases needing immediate operative intervention; (2) cases needing 
surgery which can be delayed; and (3) cases which are treated with supportive 
care only. It goes without saying in discussing surgical cases, that we must 
have available to the surgeon: cautery, suction, and special lights (if needed) 
so that surgery cannot be done in the Emergency Room or some place not 
having these facilities. 



* Staff physician of the Neurosurgery Service, USNH, Bethesda, Md. 



U.S. Navy Medical News Letter, Vol, 44, No. 5 II 

The first group of patients are those needing immediate care. What 
types of clinical conditions present as surgical emergencies? They are epi- 
dural hematoma, depressed compounded skull and spinal fractures, and some 
subdural hematomas. The need for surgery in the compounded fractures is as 
you would expect in wounds of other parts of the body. That is the prompt re- 
moval of foreign materials, debridement, and closure of wound in an effort to 
prevent infection. 

The cases that cause the greatest concern are the closed head injuries. 
The most important single clinical sign the neurosurgeon must consider is the 
level of consciousness. It should be emphasized that the level of consciousness 
is the most important sign to watch. The history of having been awake and 
lucid after the injury, followed by increasing drowsiness, should spur the phy- 
sician to very rapid action. This history is classic although It is not always 
obtained . Emergency action in this type of patient is required immediately 
because there is the possibility he can die within a few minutes. Often you read 
that the patient was awake, became increasingly drowsy, and died within fif- 
teen or twenty minutes. When one considers that it takes time to locate the 
surgeon and to set up the Operating Room, the necessity for immediate emer- 
gency action is apparent, and it is always important to keep suspected epidural 
hematoma high on the list of diagnostic possibilities. In these'cases, saving the 
patient's life is not the only prime objective, but also preserving his thinking 
ability and personality. It is really no triumph if the physician releases the 
pressure on the brain in order that the patient will live, leaving only the body 
with heart and lungs functioning, and with no soul or spirit. In one Veterans 
Administration Hospital, there were sixmen in a room, living in coma vigilans 
two to four years after their accidents. Several of them had injuries to the 
mid-brain which could not have been helped, but two of them had hematomas 
which were evacuated too late. 

As to acute subdural hematomas, their prognosis is usually poor. 
Seventy to eighty percent of them will die because the injury causing the blood 
collection also injured the brain. In doubtful cases, however, the physician 
puts in burr holes. The morbidity and mortality from burr holes is negligible, 
so the patient should be operated upon when there is only the suspicion of an 
intracranial blood collection. 

The importance of the level of consciousness in the closed head injury 
is emphasized. Unfortunately, it is possible to be misled as to a patient's level 
of consciousness if he was intoxicated when he sustained his injury. An excel- 
lent differential diagnosis of the intoxicated, head-injured patient is published 
in the Navy Medical News Letter 41(10): 8 . Whenfaced with this problem, one 
canconsider cerebral arteriography if the patient's clinical condition permits. 

If the patient has a head injury and also shock, the physician must con- 
sider causes for shock other than central nervous system trauma. Although the 
scalp can bleed profusely, shock is seldom seen in patients with central nerv- 
ous system injuries. The physician should check for ruptured viscus of the 
abdomen, fractures of the long bones, etc. 



12 U.S. Navy Medical News Letter, Vol. 44, No. 5 

The question of doing spinal punctures on these patients is raised. 
Nothing can be gained except in cases where there is blood in the cerebral 
spinal fluid indicating the patients have had cerebral contusions or lacerations. 
In the case of an epidural hematoma, spinal puncture could be dangerous in 
that the brain could be herniated at the foramen magnum by releasing spinal 
fluidbelow. If the patient has a stiff neck and the form of trauma is not known, 
it may be necessary to do a spinal tap to rule out aneurysm since the patient 
could have ruptured a cerebral aneurysm and then fallen and sustained visible 

head trauma. 

Regarding skull-fractured patients: if there are open wounds, they 
should be debrided in the Operating Room. As is true in other wounds, this 
should be accomplished immediately. If there is a depressed fracture and the 
scalp is not opened, the rule -of -thumb for elevation is that when the depression 
is greater than the thickness of bone, it should be elevated. In spinal fractures, 
if there is evidence of pressure on the cord or roots, there should be very 

early surgery. 

A patient can have extensive damage to his vertebrae without neuro- 
logic involvement. However, when in doubt as to the existence or non-existence 
of spinal injury, treat the patient as though one existed. This means, keep 
him lying face up on a firm surface and, if cervical, have the head supported 

between sand bags. 

Another group of injuries are those who have thrombosis of the carotid 
artery, secondary to trauma. The condition is one that must be kept in mind 
in the casualty who has sustained trauma and is hemiparetic and sometimes 
aphasic. The diagnosis here is made with carotid arteriography and treatment 
consists of opening the carotid artery with evacuation of the clot. 

Before leaving this group of patients, two other procedures are men- 
tioned. Do not forget to place an indwelling Foley catheter in the comatose 
patient and, if necessary, have a tracheostomy performed. The main factors 
governing the tracheostomy are the depth of the patient's coma and whether 
he is handling his mucous secretions. A patent airway is a vital, life-saving 
essential in a goodly number of these victims. 

The next large group of patients to consider are the ones who will come 
to surgery, but the need is not immediately urgent. Here we consider sub- 
dural hematoma if the patient's clinical condition is stable. If seen a few days 
after injury and arteriograms show there is a subdural hematoma, it is well 
to delay a week or so if possible. The reason for this is that it will allow the 
blood which is clotted to liquefy and thereby make the operation technically 
much easier. However, these patients must be followed carefully, checking 
their level of consciousness, strength, and vital signs frequently. 

Among this type of patient will be infants who have been developing 
poorly, have enlarging heads, or are convulsing. If the cause is a subdural 
hematoma, this can be treated by repeated tapping at the lateral aspect of the 
anterior fontanelle until the hematoma cavity closes. 

While considering pediatric problems, mention can be made of the 
depressed skull fractures in infants under two years of age. These should be 






U.S. Navy Medical News Letter, Vol. 44, No, 5 13 

elevated regardless of the amount of depression because the brain is growing 
rapidly at this age and pushing the skull out as it enlarges. 

The carotid-cavernous fistula is a complication of head injury which 
usually is noticed days or weeks after the injury. The patient always complains 
of a rushing or whistling sound in the head. A bruit can be heard over the eye 
which is proptosed and has an injected conjunctiva. This condition requires 
cerebral arteriography to evaluate the fistula and the various vessels involved. 
The treatment is trapping of the internal carotid artery in the head, ligating 
the ophthalmic artery, stuffing muscle up the internal carotid artery to the 
site of the fistula, and finally ligation of the carotid vessels in the neck on the 
ipsilateral side. 

We finally arrive at those patients whose treatment is going to be 
watchful waiting. These individuals, with closed head injuries are those whose 
level of consciousness is good enough for them to answer questions correctly. 
What will treatment be? Vital signs should be taken every one -half hour, pupils 
checked, strength (hand grip) compared, and proper reply to questions evalu- 
ated. A falling pulse, rising systolic blood pressure, weakness developing on 
one side, a pupil dilating, are all indications of increasing intra-cranial pres- 
sure and may indicate the need for quick decompression. 

X-Rays of the Skull : If the patient is intoxicated or non-cooperative, 
defer the skull x-rays until he can be still. It is a waste of film and time to 
get pictures of a moving head. Of course, if there is an open wound and a com- 
pound fracture is suspected, x-rays must be made, at least anAPand a lateral 
view. 

Medications : Patients suspected of having head injuries should not be 
sedated. If they are having pain, analgesic medications can be given. Do not 
give morphine as it constricts the pupils and you lose one of your important 
signs of trouble. Do not use medications to dilate the pupils. If you cannot 
see the fundi to check for papilledema, forget it. The papilledema usually takes 
hours to develop and again with pupils medically dilated, we cannot follow 
their natural course. 

If there has been bleeding or fluid from the nose or ear, and basilar 
skull fracture is suspected, the patient should be started on antibiotics. When 
in doubt about clear nasal fluid, send the specimen to the laboratory for glu- 
cose examination. There is no glucose in mucous secretions, but there is 
glucose in cerebrospinal fluid. If there is fluid in the ear, the Ear, Nose, and 
Throat Specialist can help in differentiating an otitis media from a cerebro- 
spinal leak. These patients should be kept in a head-elevated position. Finally, 
give Tetanus Toxoid and anticonvulsants as indicated. 



1. The Clinical Examination of Head Injuries with Emphasis upon Alcohol as 
a Complicating Factor-U. S. Navy Medical News Letter 41(10): 6, 17 May 
1963. By CAPT Robert W. Mackie MC USN. From the Proceedings of the 
Monthly Staff Conferences of the U. S. Naval Hospital, NNMC, Bethesda, 
Md. , 1961-1962. 

$ $ * * * * 



14 



U. S. Navy Medical News Letter, Vol. 44, No. 5 




MISCELLANY 



URGENT TRAINING NOTICE 

Applications for Inservi.ce Residency Training 1965-1966 

Interested applicants for inservice residency training, should carefully review 
BUMEDINST 1520. 1 OB for information concerning programs offered and pro- 
cedure for submitting applications. 

Deadline for submission for inservice training programs to begin in 
the summer of 1965 is 15 November 1964. Candidates will be notified of se- 
lection or nonselection by 15 December 1964. Applications, submitted via 
chain of command, should be for the full training program as outlined in 
BUMEDINST 1520. 10B. 

Combined programs such as in Neurosurgeiy, should be requestedfor 
the inservice portion first to begin in the summer of 1965, with the civilian 
portion to follow in a civilian institution to be determined. 

Applicants are encouraged to list at least three choices of naval hos- 
pitals for location of training if such choices exist in the chosen specialty, and 
may feel free to write the chiefs of services for details of the training offered, 

if desired. 

Early submission of applications is recommended to assure processing 
through chain of command and receipt in BuMed prior to the 15 November 
1964 deadline. —Training Branch, Professional Division, BuMed. 



On the Importance of 
Thorough Hi stories and Physical Examinations 
Durin g Enlistment Proceedings 

Foreword. The following article concerns discharges of recruits because of 
EPTE physical defects. The report covers 482 cases discharged during a 
typical six-month period for "common" type physical defects and implies that 
many or most such defects should have been discovered or more thoroughly 
explored at the time of the enlistment physical examination. The report should 
be of particular interest and benefit to those physicians required to conduct 
physical examinations for entry into naval/ military service. 

— PQ&MR Div. , BuMed. 



U.S. Navy Medical News Letter, Vol. 44, No. 5 15 

Physical Defects in Recruits 

By LT John R. Judge MC USNR* 

With the increasing awareness of relatively more physical and mental dis- 
abilities inherent within our younger population, it particularly behooves exam- 
ining physicians, military and civilian, to be especially diligent during a phy- 
sical examination of the younger patient. Too often, the patient's youth with 
its implied health, is the rationale for the somewhat cursory examinations 
sometimes given to this particular group, both in private practice and in or- 
ganized groups such as represented by school athletic physicals or military 
pre and post induction /enlistment examinations. 

The consideration of cost, both monetary and in physical aggravation, 
as a result of non-detection during a physician's examination is tremendous. 
The moral responsibility of a physician to render the best physical examination 
possible, speaks for itself. 

The following data represent a typical six month period of the more 
common type defects which discharged recruits for physical defects from the 
United States Naval Training Center, San Diego, California, after all had pur- 
portedly received thorough enlistment physical examinations which did not in- 
dicate any abnormalities. This number, totaling 48Z, is not indicative of the 
total number surveyed. 

Joint Defects, Traumatic /Congenital . By far the largest single type 
entity encountered was in the orthopedic realm. This represented 21. 9% of all 
cases seen. Most were post traumatic knee joint derangements suffered in 
athletic or car accidents, but also seen were cases of tibial torsion and genu 
valgus; chronic shoulder dislocation cases, some postoperatively and still 
symptomatic ; chronic patellar dislocations; talipes equino varus; post traumatic 
arthritis involving hips, elbows, knees and feet; osteochondritis dissecans; 
and "loose bodies" within joints. The one constant finding in almost every one 
of these cases was the fact that each had been previously symptomatic, had 
told the examiner of his defect(s) or in fact had an obvious deformity to even 
casual observation. On questioning, some related the examiner looked at th.-' 
member briefly, while others did not acknowledge or indicate further interest. 

Dermatitis. The second largest grouping of surveyed patienA? was rep- 
resented by various dermatological entities. This group, representing 10.3% 
of the total, included: Atopic dermatitis; (neurodermatitis); a:ne conglobata; 
ichthyosis, severe; chronic eczema; psoriasis; dermatitis venenata; dermo- 
graphism; hydradenitis and epidermolysis bullosa. While sjme of these cases 
claimed no previous knowledge (mostly the atopic dermatitis cases) the re- 
mainder showed dermatological sequelae when examined and all had indicated 
both on enlistment forms and to the examiner, a past history of dermatological 
difficulties. In no case was further examination performed or consultation ob- 
tained, and each man was then considered as a fully healthy individual (by 

* Dr. Judge was in charge of the Medical Survey Branch, Naval Training 
Center, San Diego, Calif. , from 11 September 1963 to,8 July 1964. 



16 U.S. Navy Medical News Letter, Vol. 44, No. 5 

standards). While some dermatological lesions can be a puzzle to the average 
physician, their existence or potential should not be ignored. 

Chronic O titis Media /Tympanic Perforations . The group representing 
chronic previous ear infections and/or sequelae is almost as large as the skin 
conditions category. This group comprising 9.4% of all cases, consisted 
mainly of patients with tympanic membrane perforations secondary to previous 
recurrent otitis. Also seen were badly thickened and scarred membranes 
secondary to infection; cholesteatoma conditions; and traumatically injured 
membranes. Of interest is the fact that in every single case each man stated 
a physician had performed an otological examination with an otoscope. Almost 
as amazing is the fact that all but four patients stated they told the various 
examiners of the previous ear infections or difficulty, yet, not one patient of 
the group had been told of any ear abnormality while being examined for the 
service. The conclusions to be drawn from this situation indicate ineptitude 
or indifference on the part of the examiners. 

Hernias /G. U. Defects . Next in prominence was the group representing 
hernias or genito -urinary defects. This group, which made up 10. 3% of the 
total, mainly had simple unilateral inguinal hernias. Also seen, however, were 
cases of cryptorchism; varicocele; spermatocele; and both epispadias and 
hypospadias, not to mention several cases of testicular agenesis. Upon ques- 
tioning each man, it was revealed that only approximately one/third had been 
examined for hernia, although each had stood naked during the entire course 
of the physical examination. 

Congeni tal/ Traumatic Limb Atrophy . In much the same vein, 4. 1% of 
cases were teen with obvious physical deformity of a limb. Although most 
were of traumatic origin, there was even a case of spasticity secondary to 
documented birth trauma. Every patient in this group readily related the de- 
tails and incapacities of his arm, hand, leg, or other part. Yet, in every case, 
each related he had been "looked at" by a physician. It is, of course, most 
difficult to surmise the rationale behind the acceptance for military service 
of each of this type patient. Medical skill certainly does not play a part, as 
even a lay person might well discern that something was amiss in merely looking 
aft these individuals. In fairness, it might be assumed that a humanitarian 
motive, albeit misguided, prompted the acceptance of these patients in the hope 
of "giving *hem a break, "although it is hard to reconcile the complete ignoring 
Of medical fa-ts of this nature or probability of eventual discovery, with this 
motive, 

Asthma. In this group which represented 3. 5% of cases, were seen 
mainly patients with long -standing asthmatic -type respiratory difficulty. Most 
were medical problems from theonsetof military training and, as such, were 
seen for acuta epi sides of difficulty which required systemic therapy. In all 
but two cases, each man stated that he had indicated a previous history and/or 
current therapy at the time of his original examination, yet not one was de- 
tained for corroboration nor was any further interest or action taken other 
than the auscultation performed on the chest. One patient with an established 
diagnosis of mucoviscidosis and recurrent pneumonia problems brought his 



U.S. Navy Medical News Letter, Vol. 44, No. 5 17 

own physician's statement to the examiners but after auscultation was also 
passed. The waste in effort and money expended in processing these people 
could well have been averted if the old physical diagnosis adage "listen to the 
patient, he will tell you what is wrong, " had been heeded, and corroborative 
investigation had been pursued. 

Deafness . In this group, which was considered exclusive from post 
infectious sequelae deafness, there was 4. 5% of total cases. Some were uni- 
lateral and some represented bilateral deafness of70decibel average loss. In 
review of statements made at the time of initial examination in each case, every 
man stated he admitted difficulty previously with auditory acuity. Most did not 
show evidence of anatomic derangement on otoscopic examination, yet to simple 
clinical testing with tuning fork and whispered voice all showed diminution of 
hearing acuity. Even without more specific testing to determine the type of 
deafness inherent within each man, all should have been initially selected for 
more precise audiogram examination with these findings to determine the de- 
gree of deafness. Yet, not one was even questioned at length regarding his ad- 
mitted hearing deficit, nor was any notation made of auditory deficit. The 
motivation to ignore findings of this nature may well be that the examiner felt 
in each case, that the defect was not "too bad" and that the patient could "get 
along" even with it. 

Heart Defects /Congenital/ Acquired . Of particular medical interest is 
that represented by the group of cardiac problems. This group, comprising 
4. 3% of cases surveyed was remarkable in that a very notable murmur or 
adventitial heart sound was evident in every case. While the majority of cases 
represented post rheumatic fever valvular sequelae there were also several 
congenital/acquired type lesions, including incomplete septal closures; parox- 
ysmal atrial tachycardia and previous pericarditis. While it is obvious that 
only a highly trained cardiologist can interpret the more subtle differences in 
murmurs sufficiently well to establish esoteric diagnoses, it is well within the 
province, or at least should be, of the average practitioner to distinguish definite 
indications of current or remote cardiac pathology and to followup these indi- 
cations with more definitive procedures within his competence or to seek ad- 
vice on matters beyond his training. In every single case represented here, 
the patient had a preinduction physical including auscultation of the heart, yet 
not one of these stated he was questioned about having a murmur, although 
each had a very significant, quite audible murmur or adventitial sound on ar- 
rival at this base. 

While undoubtedly the requisite further examination of any patient cre- 
ates a problem of inconvenience for both the patient and examiner, as well as 
adequate number of examiners, it is unquestionably more economical in terms 
of later health, monetary and even legal considerations. 

There is no accurate gauging of the effort and money wasted which could 
have been avoided very simply if the individual examiners in each of the said 
case shad not glibly passed the "aberrant cardiac sound , " and had sought either 
specialist advice or had frankly found the man disqualified with findings which 
obviously preclude military duty according to accepted standards. 



18 U.S. Navy Medical News Letter, Vol. 44, No. 5 

In a similar situation, but in smaller numbers { 1. 6%), were seen visual 
acuity defect cases including surgically aphakic eyes; complete suppression 
amblyopia unilaterally and mature cataracts -all of whom had purportedly been 
given a thorough physical examination previously. In these smallgroups total- 
ling 9% were also seen several cases of chronic osteomyelitis;some still man- 
ifesting purulent drainage from various sites; bone tumors; hypertensives; 
pilonidal cysts; congenital spinal deformities and active pulmonary tuberculosis 
cases (all of whom had had chest x-rays performed and read prior to reporting 

for active duty). 

The remainder of cases were of such a nature that a complete physical 
examination would not necessarily have revealed the difficulty. All told this 
group was much smaller than the total of the aforementioned conditions. There 
were included convulsive disorders; cerebral aneurysm; hemophilia; various 
renal defects bothcongenital and acquired; peptic ulcer and migraine headaches. 
Except for deliberate concealment of symptomatology, as was seen in most 
of the convulsive patients, there was ample evidence that most of the other 
cases had attempted to convey to the examiners existence of previous difficulty 
both verbally or on application forms. Unfortunately, in these cases, no further 
action was taken until after these men had formally been enlisted in the naval 
service. 

While there are undoubtedly a variety of reasons why these men were 
not found to have disqualifying defects, initially, the one main reason seems 
to be that each did not receive as careful an examination as he deserved. There 
can be no doubt that large numbers to be examined and limited time do contri- 
bute to a somewhat hastened and cursory examination. Here, however, is just 
where extra effort must be expected and demanded. The slight additional time 
required to more adequately assess each patient can prevent the wasted efforts 
of literally dozens of individuals who must do the further reexaminations, 
clerical and administrative work in order to correctly dete rmine a man' s status. 
A plea is made on this basis, as well, for a tempering of what may be genuine 
humanitarian motives in passing a boy who is known to the physician as being 
physically disqualified. While a "large heart" is a definite requisite in the art 
of medicine, it should not cloud the scientific aspect of potential harm which 
can accrue when a known defect is deliberately ignored. Even the psychological 
effects are worse on the patient when he eventually is discovered to have a 
disqualifying defect. 

This extra effort can only come about through individual motivation of 
every physician who examines this type patient and it is to be fervently hoped 
that this trait is still inherent within most of our physicians. 



Mortality from bronchitis varies widely from country to country in Europe, 
being particularly high in those whose industrialization is basedon coal. Thus 
in 1959 the rate was no more than 5-10 per 100, 000 population in the Scandi- 
navian countries, as compared with 64 per 100,000 in England and Wales. 
-WHO Chronicle 18(3): 89, March 1964. 



U.S. Navy Medical News Letter, Vol. 44, No. 5 19 

Honor Awards Offered By Freedoms Foundation, Valley Forge. Cash and 
honor awards are still available for your thoughts on your right to vote. All 
Armed Forces personnel are reminded of the awards offered annually by 
Freedoms Foundation at Valley Forge for outstanding statements written by 
military personnel. The awards include cash awards of up to $1, 000, George 
Washington Honor Medals, and participation in the awards presentation cere- 
monies in Washington, D. G. , and Valley Forge this winter. The Principal 
Award recipients will ride in the parade in the Presidential Inauguration. 

To compete, a "letter" of 100-500 words on the subject "My Vote: 
Freedom's Privilege" should be written and submitted to Freedoms Founda- 
tion, Valley Forge, Pa. , before November 1st. No entry fees or official nom- 
ination forms are required. Full military identification and address should 
be shown. 

The awards are selected by a distinguished independent jury composed 
of justices from the state supreme courts and the heads of the nation's leading 
patriotic, veterans and service club organizations. The awards offered to 
Armed Forces personnel are a part of the Freedoms Foundation annual Awards 
Program designed to recognize individuals, organizations, governmental units, 
and schools for the things which they have written, said or done which bring 
about a better understanding of the ideas and ideals set forth in our Constitu- 
tion, our Bill of Rights, and the Declaration of Independence. 

Freedoms Foundation is a nonprofit, nonpolitical, nonsectarian organ- 
ization founded in 1949. General Dwight D.Eisenhower heads the Foundation's 
Board of Trustees representing Americans from the fields of education, the 
arts, science, business and the military. 

#ft 3JE *fi- S[! 5p Vfi 

Annual Physical Examination of Inactive Flag and General Officers of the 
Naval and Marine Corps Reserve. In June 1964 BUMED advised cognizant 
district commandants that all flag and general officers of the inactive Naval 
and Marine Corps Reserve should undergo an annual physical examination 
similar to that currently required for flag and general officers on active duty 
(MANMED art. 15-45(4)). 

Correspondence has been received in BUMED to the effect that cer- 
tain senior officers have he en referred to various Army and/ or Air Force hospi- 
tals for their annual physical examination without adequate instructions. That 
is, neither the officer concerned nor the examining facility were aware of the 
exact type or scope of physical examination required. It is suggested that in 
those cases where referral to an examining facility of one of our sister serv- 
ices is necessary to accomplish the annual physical examination, that both the 
officer and examining facility be advised of the exact type and scope of the 
physical examination that is required, i. e. , "Annual Executive Type. " 
— Physical Qualifications and Medical Records Division, BuMed. 

****** 



20 U. S. Navy Medical News Letter, Vol. 44, No. 5 

FROM THE NOTE BOOK 

Doctor Benoit Sets Good Example of Authorship 

When LCDR Fred L. Benoit III MC USN, departed from Oakland Naval Hospi- 
tal on July 17 for a new assignment at the Naval Medical Research Institute, 
NNMC, Bethesda, Md. , Oak Knoll lost her most prolific contributor to scientific 
literature. 

Dr. Benoit has been assigned to the Medical Service and Clinical In- 
vestigation Center in Oakland for the past four years. He submitted his first 
paper 26 months ago and since then has had five papers published and two ac- 
cepted for publication. His contributions have been in fields of metabolism, 
endocrinology, renal disease, and infectious diseases. He has collaborated 
with members of the Clinical Investigation Center, Pathology and Medical Serv- 
ice Staffs. 

To date, more than a thousand requests for reprints of his articles 
have been received from various parts of the United States and 34 foreign 
countries. Three more papers have been submitted, and six are in various 
stages of preparation for publication-all to be submitted from Oakland. 

In addition to writing for publication, Dr. Benoithas been senior author 
or co-author of a number of papers accepted for presentation at local, regional, 
national, and international scientific meetings. All manuscripts have been 
edited and prepared for publication by Mrs. Mullie Jack, CIC publications 
editor. 

Dr. Benoit earned his MD at the University of Washington School of 
Medicine, interned at Oakland, and served at Naval Air Station, PearlHarbor, 
Hawaii, before returning to Oakland in I960. 

— From PIO, Oak Knoll. Submitted by RADM C. L. Andrews MC USN, CO, 
USNH, Oakland, Calif. 

$ s^ sf: ;Je sjc sjs 

American Board Certifications 

American Board of Anesthesiology 

' LCDR Charles P. Larson, Jr. MC USNR 

American Board of Internal Medicine 

LCDR Paul Ivan Jagger MC USNR 

American Board of Obstetrics and Gynecology 
LCDR Paul D. Mozley MC USN 
LCDR John C. Robins MC USN 

American Board of Ophthalmology 

LCDR Wayne R. Wilson, Jr. MC USN 



U.S. Navy Medical News Letter, Vol. 44, No. 5 Zl 

American Board of Orthopaedic Surgery 

CAPT Newman A. Hoopingarner MC USN 
CDR Howard S. Browne, Jr. MC USN 
LCDR Hugo S. Deluca MC USN 
LCDR Abel R. Ellingson MC USN 
LCDR Glendall L. King MC USN 

American Board of Pathology 

CDR Frank G. Steen MC USN 
LCDR Norman M. Horns MC USNR 

American Board of Pediatrics 

LCDR Dennis F. Hoeffler MC USN 

American Board of Preventive Medicine (Aviation Medicine) 
CDR Frederick D. Beckwith MC USN 
CDR Robert C. McDonough MC USN 

American Board of Radiology 

CAPT Ernest A. Zinke MC USN 
LT Ronald A. Swanson MC USNR 

American Board of Surgery 

LCDR Robert D. Belser MC USN 
LCDR Richard G. Fosburg MC USN 
LCDR Harvey P. Rubin MC USNR 

SjC 9fc % * # $ 

CNO's Message on the President's Economy Program. The following message 
has teen received from the Chief of Naval Operations: 

"In a one hour meeting with President Johnson, he repeatedly em- 
phasized his appreciation of the steps which the Armed Services had taken in 
the implementation of his program to insure that we get the most for each 
Defense dollar spent. It is his desire that each individual and each unit know 
that he is pleased by these results which indicate to him that we have full ap- 
preciation of the need for frugality and prudence in carrying out our responsi- 
bilities. Keep up the good work. " — T. I. O. , BuMed, 5 August 1964 . 

Smallpox Drug. A new drug to control smallpox has been successfully tested 
in Madras, India. Between February and July 1, 1963, 1,100 persons who 
had been inclose contact with the infection were given n-methylisatin betathio- 
semicarbazone (B. W. 33-T-57). Only three mild cases of smallpox occurred 
among them, and in two of these the full dosage had not been taken. In a simi- 
lar number of exposed persons who did not receive the drug, although most 
had been vaccinated, there were 76 cases of smallpox, 12 fatal. (Lancet, Sep- 
tember 1963). —Public Health Reports 79(2): 136, February 1964. 



22 U. S. Navy Medical News Letter, Vol. 44, No. 5 




L kfflJ SECTION 



Dental Abnormalities in Rats Attributable to Protein 
Deficiency During Reproduction 

James H. Shaw and Derrick Griffiths. Jour of Nutrition 80: 123-141, 
June 1963. 

This paper is one of the few exciting studies to be reported for those interested 
in genetics, nutrition and caries susceptibility. This study was directed toward 
a determination of the effects upon the oral tissues of changes in the carbo- 
hydrate — protein ratios imposed during prenatal and early postnatal life. The 
experiments were conducted with two strains of caries -susceptible rats and a 
strain of caries -resistant rats. A standard low-protein diet containing 8% 
casein fed to the females during the reproductive cycle caused in the offspring 
of all three strains, a high mortality during lactation, very low body weights 
at weaning, reduction in the size of the molars, delay in third molar eruption, 
high frequency of missing cusps on third molars and increased caries activity 
in the occlusal sulci and on the smooth surfaces of the molars. Post-weaning 
supplementation of the diet to correct the low protein content was too late to 
correct the abnormalities. 

With a great proportion of the world population on suboptimal protein 
intake, this study increases in importance, as it clearly demonstrates that 
nutritional abnormalities may cause deviations from the genetically established 
blueprint for development of the dental structures. 

(Submitted by CAPT F. L. Losee DC USN, U.S. Naval Training Center, 
Great Lakes, Illinois) 



Effect of Sodium Monofluorophosphate Solution on 
Caries Rates in Children 

Goaz, McElwaine, Biswell and White, University of Oklahoma School 
of Medicine, Division of Dentistry, J D Res 42(4): 965-972, July - 
August 1963. 

A solution of 6% Sodium Monofluorophosphate was self applied witha toothbrush 
by school children ages, 6 - 14 in Tulsa, Oklahoma, where the water supply 
has been fluoridated for 10 years. This, pleasantly flavored pink solution was 



U. S. Navy Medical News Letter, Vol. 44, No. 5 23 

applied daily for a 9 month period and then continued on for 5 months or a 14 
month total time. 

The children did not use a fluoride dentifrice and did not have topical 
application of fluoride during the study. At the end of 9 months there was a 
30. 9% reduction in the R. I. D. (Relative Increment of Decay). This is a ratio 
of the number of surfaces becoming carious or filled during a given period to 
the total number of surfaces at risk. For comparison, the decay activity also 
is presented as the difference between the number of noncarious surfaces 
initially present (plus those surfaces that erupted minus the number of noncarious 
surfaces lost) and the number subsequently found to have remained noncarious. 
This difference is the number of new decayed and filled surfaces A DFS. During 
the 9 month period there was a reduction of 25% in A DFS. 

There was an even greater reduction over a 14 month period in both 
RID andADFS, it being 34. 9% and 42.1% respectively. 

Renewal and remineralization (over the control group) was found to be 
41% in 9 months and 66% in 14 months. 

The results indicate a significant, additive anticariogenic effect of 
sodium monofluorophosphate to that accruing from water fluoridation. 

(Submitted by CDR R. E. Austin DC USN U.S. Naval Training Center, 
Great Lakes, Illinois.) 

•J* -tr *>s -.•> -.*' -A* 

•Tf. *■£>* Sf, Jf. jf. Of* 

Communications and Health Education 

A review of material contained in writings by Sanford, F. I. , "Inter- 
personal Communications", Industrial Medicine and Surgery 25: 261, 
May 1956 and by Kent, R. M. , "Health Educators at Work" 1952. 

Each morning as the impressive ceremony of "colors" is conducted aboard 
ships and stations of the United States Navy, a new day begins for the officers 
and men of the U. S. Navy Dental Corps who have assignments in these facilities. 
For them it means beginning anew the constant battle against dental disease — a 
struggle which has long been gallantly waged by the meritorious efforts of 
clinical dentistry. 

This war cannot be won, however, by treatment of the disease alone. 
Preventive measures must be utilized by the masses if we are to hope for the 
ultimate control of dental disease. 

There are at present many excellent preventive measures which are 
known and practiced, but unfortunately only a relatively small number of people 
are receiving the benefits from them. 

The major problem existing now is to reach a much larger proportion 
of our population and, through various dental health education experiences, 
hopefully effect a change from their present pattern of behavior to embrace 
better dental health habits which should in time substantially reduce the incidence 
of new dental disease. 



24 U. S. Navy Medical News Letter, Vol. 44, No. 5 

Communication, of knowledge to others then becomes a prime essential 
in any preventive dentistry program. SANFORD states, however, that mere 
interpersonal noise that often transpires between the disseminator of information 
and the recipient of that information is no guarantee of the effectiveness of that 
information. These speakers are somewhat akin to the archer who pays more 
attention to his bow and arrow than to the target he wishes to hit! 

It is by no means sufficient to expose any individual or group to only 
one type of learning experience. Neither does it suffice to expose them to only 
one such experience. KENT has stated that not one, or two, but a series of 
health education experiences will be necessary to carefully stimulate people to 
the actual point of changing their attitudes and behavior for their own welfare 
and benefit! 

Dental equipment has improved, new drugs are available, and more 
modern techniques are taught in our dental schools, yet all of these are of little 
avail if we do not reach the mind and spirit of the individual. Dental research 
is providing new and valuable information in this fight against dental disease, 
but it still remains for some to venture forth into the populace and through 
teaching, communication and demonstration, improve the people's knowledge 
and appreciation of better dental health. 

It is not enough that the profession itself continues to become more 
edified at a time when misinformation, ignorance, resistance to change, lack 
of motivation and apathy among the laity still remain as barriers in our quest 
for the control of dental disease] 

(Commentary on the place these important subjects have in Preventive 
Dentistry submitted by CDR R. E. Austin DC USN, U. S. Naval Training Center, 
Great Lakes, Illinois. ) 

■J.* "*.*.*■ %JL* O j- *l* <!*■ 

rf* rg* rfi ^f* >p *^ 

Personnel and Professional Notes 

New Packaging of Caries Prevention Treatment Agents . Stannous fluoride and 
the compatible Special Pumice Mixture have been made available in bulk quantities 
for Navy Dental Corps usage. Open purchase orders may be directed to Mr. A. P. 
Austin, Procter and Gamble Company, Winton Hill Technical Center, 6000 
Center Hill Road, Cincinnati 24, Ohio. The items are: Stannous Fluoride, 
300 gm bottle, cost $5. 00 and Special Pumice Mixture for Stannous Fluoride 
Prophylaxis, 4 lb bottle, cost $10.00. 

Eleven Dentists Complete Casualty Care Course . Eight dental officers of the 
U.S. Navy, two dental officers of the U.S. Air Force, and one civilian dentist 
who attended under the auspices of the ADA, have completed the Casualty 
Treatment Training Course at the U. S. Naval Dental Clinic, Norfolk, Virginia. 
The course, under the supervision of the Bureau of Medicine and Surgery, is 
one of several conducted throughout the Navy to develop in dental officers such 
skills in emergency casualty treatment as to make full use of their professional 



U. S. Navy Medical News Letter, Vol, 44, No. 5 25 

knowledge, thus enabling them to amplify the medical effort in time of major 
emergency. This is the third course to be conducted at Norfolk this year. The 
Casualty Treatment Training Course is under the direction of CAPT E. W. Small 
DC USN, Head of Oral Surgery. RADM E. G. F. Pollard DC USN, is Command- 
ing Officer of the U. S. Naval Dental Clinic. 

Reporting Defective or Unsatisfactory Material . Joint FMSO-FLDBRBUMED- 
INST 6700.16A outlines the correct procedure for submission of Defective 
Medical Material complaints. Review of these complaints held by the Defense 
Medical Supply Center's files disclosed that activities are not submitting two 
(2) copies of this report to the Chief, Field Branch, Bureau of Medicine and 
Surgery, 3rd Avenue & 29th Street, Brooklyn, New York 11232. 

Correction to Training Publication. Training Publications for Advancement 
in Rating, NavPers 10052-L, on page 59, incorrectly identifies Early Medical 
Management of Mass Casualties in Nuclear Warfare, NavMed P-5046. BuPers 
is aware of this error and will correct it as soon as possible. 

Naval Dental School Requires Prosthetic Journals . The U. S. Naval Dental 
School requires the following backissues of the Journal of Prosthetic Dentistry 
to complete a series of reference texts: 

4, 5, 6 



1951 - 


Volume 1, 


No. 


1, 


2, 3, 


1954 


Volume 4, 


No. 


1, 


2, 6 


I960 


Volume 10, 


No. 


5 




1961 ■ 


Volume 11, 


No. 


2, 


3, 4 


1962 


Volume 12, 


No. 


5, 


6 



It will be appreciated if any dental activity or individual can provide copies of 
the missing issues. Please send directly to: Commanding Officer, U.S. Naval 
Dental School, National Naval Medical Center, Bethesda, Maryland 20014. 

Last Epdoconus Flank-Owner Honored Upon Transfer . On 30 June, Master 
Chief Dental Technician Eugene A. KENNEDY was honored at a ceremony 
conducted by the Commanding Officer, Enlisted Personnel Distribution Office 
for Continental United States, Bainbridge, Maryland. 

The occasion was Master Chief KENNEDY'S impending transfer from 
EPDOCONUS to sea duty. This event marked the departure of the last original 
EPDOCONUS crew member. Master Chief KENNEDY reported to EPDOCONUS 
shortly before the command's commissioning in January of I960, thereby 
becoming a qualified "plank-owner". 

While attached to EPDOCONUS, Master Chief KENNEDY served as the 
Dental Technician personnel distributor for Continental United States. His 
performance of duty in that billet was so exemplary that letters of commenda- 
tion from RADM F. M. KYES, Chief of the Dental Division of the Bureau of 
Medicine and Surgery, and from CAPT A. J. LITTLE, Commanding Officer, 
EPDOCONUS, were presented to him at the ceremony. RADM KYES' letter 
noted that Master Chief KENNEDY'S "personal attributes of loyalty, dignity, 



26 



U. S. Navy Medical News Letter, "Vol. 44, No. 5 



unswerving integrity, and absolute impartiality, combined with a broad knowl- 
edge and thorough understanding of personnel distribution procedures, have 
contributed immeasurably to the accomplishment of the mission of the Dental 
Division. " CAPT LITTLE pointed out in his letter that Master Chief KENNEDY'S 
"interest, enthusiasm, and experience were of great value in construction of 
a workable and equitable distribution program for Dental Technicians"; and that 
he had "continued to strive for improvements which were of benefit to the entire 
Command. " Master Chief KENNEDY was presented with these letters and a 
plaque carrying the mounted EPDOCONUS seal the day before he was transferred 
to Hawaii. 










I 



"Official U. S. Navy Photograph" by Photographers Mate 
Second Class Harold D. Phillips (PH2) USN. Bainbridge Md. 
Presentation of commendation letters to Chief KENNEDY 
of EPDOCONUS by Captain Little, Commanding Officer, 
EPDOCONUS, on 30 June 1964. 

Nine Bay Area Dental Corps Officers Attend Course . CAPT J. J. Dempsey 
DC USN, dental officer, U. S. Naval Station, Treasure Island, California 
hosted a short postgraduate course of instruction in Practical Clinical Endo- 
dontics 1-5 June 1964. Guest instructor was CAPT Charles E. Rudolph Jr. 
DC USN of the U. S. Naval Training Center, San Diego, California. 



Dental Officer Elected to Membership in Dental Society . CAPT Harvey W. 
Lyon DC USN, Director, Dental Research, Naval Medical Research Institute, 
National Naval Medical Center, Bethesda, Maryland has been elected to 
membership in the American Academy of Oral Pathology. 



U. S. Navy Medical News Letter, Vol. 44, No. 5 27 




OCCUPATIONAL MEDICINE 



Houston to Host Occupational Health Congress * 

CHICAGO — The 24th Annual Congress on Occupational Health will be held in 
Houston, Texas, September 26 - 27, and sponsored by the American Medical 
Association's Council on Occupational Health. The two-day meeting will be 
at the Rice Hotel. 

Saturday morning's opening session will be devoted to a discussion of 
"Cardiology in Industry. " Physician participants include George Burch, Chair- 
man, Department of Medicine, Tulane University School of Medicine; Frederick 
Stare, Professor of Nutrition, Harvard University School of Public Health; 
John Moyer, Professor and Chairman, Department of Medicine, Hahnemann 
Medical College and Hospital; Raymond Pruitt, Professor and Chairman, 
Department of Internal Medicine, Baylor University. 

Immediately preceding the noon recess, the annual Physician's Award 
of the President's Committee on Employment of the Handicapped will be pre- 
sented to John S. Young, MD, Denver, for his outstanding work in this field. 

The conferees will tour the new NASA Manned Spacecraft Center 
Saturday afternoon and will be briefed on progress in America's Gemini and 
Apollo space programs. An astronaut will address the gathering. 

A symposium on "Treatment of Burns" will open the next day's program. 
Participants will include members of the Department of Surgery, University 
of Texas. 

The morning session will close with a three -point discussion of "Problems 
of General Physicians. " Topics include "Investigation and Medical Testimony 
on Death from Doubtful Causes, " "The Nurse Who Works Alone, "and "A General 
Practice Plan for Periodic Health Examinations in Very Small Employee Groups. " 

Pesticide poisoning, toxic exposures and health programs for radiation 
workers will be the subjects on the agendaforthe afternoon symposium entitled 
"Environmental Health Services. " 

The concluding assembly will deal with the practical expectations for 
rehabilitation of the severely impaired person, with case presentations from 
Baylor University. 

For more complete information write to: Council on Occupational 
Health, American Medical Association, 535 North Dearborn, Chicago, Illinois, 
60610. 

*News Release from the American Medical Association. 



28 U. S. Navy Medical News Letter, Vol. 44, No. 5 

Gl tie - Sniffing 

National Clearinghouse for Poison Control Centers, U.S. Department 
of Health, Education, and Welfare, Public Health Service, Washington, 
D. C. 20201, July - August, 1964. 

In recent years there has been very little new knowledge on the glue solvents; 
the same applies to their toxicity. However, there are several aspects of this 
problem that can be updated. 

Legal efforts have been made to discourage and prevent glue -sniffing in 
our teen and pre -teenagers. A California municipality has made it illegal for 
a person to: .... inhale, breathe or drink any compound, liquid, chemical, or 
any substance known as glue, adhesive cement, mucilage, dope, or other 
material or substance or combination thereof, with the intent of becoming in- 
toxicated, elated, dazed, paralyzed, irrational or any manner changing, dis - 
torting or disturbing the eyesight, thinking process, balance, or coordination 
of such person. 

In Maryland a law was enacted making it: .... unlawful for any person 
under twenty-one years of age to deliberately smell or inhale such excessive 
quantities of any narcotics, drugs, or any other noxious substances or chemicals 
containing any ketones, aldehydes, organic acetates, ether, chlorinated hy- 
drocarbons or any other substances containing solvents releasing toxic vapors, 
as cause conditions of intoxication, inebriation, excitement, stupefaction, or 
dulling of the brain and nervous system. Any person violating this section 
will be guilty of a misdemeanor and upon conviction thereof shall be fined. 

Several other cities and states have enacted or have proposed legislation 
on glue -sniffing. This legislation is of two types. As in the examples stated, 
one form is directed towards the promiscuous users of these solvents. Another 
is directed at restricting the sale of products containing these solvents, as in 
the New York City ordinance. Washington, D. C. , and other areas have included 
both approaches, 

A method aimed at eliminating the inhalation of toxic vapors and which 
would eliminate the glue-sniffing practice has been the placement of responsi- 
bility on the manufacturers of glues. The Hobby Industry Association in its 
position statement on glue-sniffing recognized "glue -sniffing as a sociological 
problem that is a part of a greater and older social evil, namely, intoxication." 
The association, however, implemented a program that has both technical and 
educational phases. On the technical side, a leading biochemical laboratory 
was retained to develop a substance which could be added to model glue to 
produce sneezing, nausea, or other unpleasant effects if purposely inhaled in 
excessive concentrations; and/or a substitute solventto be used in the formula- 
tion of model glue. At the same time, a comprehensive public education 
campaign was initiated. It included a program directed at business outlets to 
limit the sale of glue to bonafide model builders. The Hobby Industry Association 
also produced a color motion picture film on the subject to supplement public 
educational and information programs. 



U. . S. Navy Medical News Letter, Vol. 44, No. 5 29 

The fourth conference on inhalation of model airplane glue solvents was 
held in Berkeley, California, on January 17, 1963. It included representatives 
of industry, law enforcement and health agencies. At this meeting it was 
reported that of 94 additive compounds which were under investigation in 1962, 
48 were selected and 47 were investigated with a final choice narrowing the 
field to 17. The most promising solvents which are inert physiologically as 
well as nonflammably are the Freons. The most important factor was that, 
while toluene produces intoxication, Freons do not. However, this hopeful 
anticipation of new solvents to replace those that are now in use is not shared 
universally, even among members of the glue industry itself. 

Although a statistical description of a problem is not necessary to 
appreciate its existence, there are many unanswered problems. None of the 
studies conducted thus far indicates conclusively that this practice occurs more 
frequently in the lower socio-economic groups; or if the problem is still in- 
creasing, or decreasing. Reports of glue-sniffing cases have come from 
various sources, ranging from police departments to health departments; the 
diverse types of reports make statistical analysis difficult. 

The toxicity from this practice of glue sniffing is still poorly defined. 
There have been at least 9 deaths, 6 of which have been associated with a 
plastic bag over the victims head. Another death is presumed to have been 
due to a plastic bag. In two other cases, the glue-sniffing death was believed 
due to inhalation of organic solvents. 

In the years 1962 and 1963 the National Clearinghouse has received only 
16 reports of glue-sniffing from the poison control centers throughout the 
country. Undoubtedly this does not reflect the true incidence of this practice. 
One deduction is that glue -sniffers consider the practice to be non-harmful. 
The great majority of reports were in the teenage group. In six telephone 
inquiries there were no symptoms mentioned for teenagers who had been inhaling 
the fumes of these cements for as much as 3 months. In eight telephone 
inquiries symptoms ranging from headache, dizziness, breathlessness, intoxi- 
cation, unconsciousness, hematuria, blurred vision, and paleness were 
stressed. In the four "treated" cases in this series one had symptoms of 
depression, stupor, and dyspnea and the other had psychological changes 
described by the mother as irritability, moodiness and fright. Unfortunately, 
none of these cases had a known medical follow-up. The finding of hematuria 
in one case was not substantiated as caused by the glue solvents. In the other 
two "treated" cases, the symptoms were unknown. 

Other case reports of physical injury reviewed by the National Clearing- 
house have shown no conclusive pattern. That two young patients who used 
airplane cement developed hypoplastic bone marrow in one case and aplastic 
anemia in another, is certainly a matter to be recorded but not a cause and 
effect association. Dr. Jacob Sokol studied 89 glue sniffers confined to Juvenile 
Hall in Los Angeles and compared their blood and urine findings with a sample 
group from the same institution who were known as nonglue- sniffers. His 
results suggested anemia as a peculiar toxic manifestation, since all members 



30 U. S. Navy Medical News Letter, Vol. 44, No. 5 

of the control group showed normal blood counts. Other blood findings were a 
change in the form, shape, and color of erythrocytes and leukocytosis. 

Apart from physical injury produced by inhalation of solvents from glues, 
incalculable harm can be done while youngsters are under its influence. They 
have learned to experience an effect outwardly similar to alcoholic intoxication 
by inhaling the concentrated solvent fumes of plastic cement and airplane glue. 
At first the reaction is one of mild intoxication, exhilaration, euphoria, and 
excitement. Then the sniffer begins to act drunk, becomes uncoordinated, and 
slurs his words. As one youngster described his sensations: "I saw two of 
everything and everything far away looked real near. I had noise in my ears 
like a firecracker going off, and then I blacked out. " 

Euphoria may be accompanied by a feeling of reckless abandon, some- 
times with grandiose notions as to physical or mental capabilities. These 
sensations occasionally lead to impulsive acts which, otherwise, would have 
been unlikely. One boy in his early teens was so exhilarated by glue sniffing 
that he assumed a fighting stance before an oncoming freight train, narrowly 
escaping death. 

In San Francisco, a 12 year old youngster who had never been known to 
steal, robbed a florist shop while under the influence of glue -sniffing. Another 
youngster jumped off a low building, convinced he could fly. 

One rather small 16 year old boy picked a fight with four sizeable marines 
and could scarcely believe he had been defeated; four teenagers who were 
arrestedby police after a 70 -mile an hour automobile chase through Washington, 
D. C. were intoxicated from glue solvent inhalation. 

Many of these young people describe a feeling of complete detachment 
from their surroundings. There is some evidence that this impulsive or 
destructive behavior can be more frequent among glue-sniffers than in persons 
acutely intoxicated by ethyl alcohol. One police official noted: "Imagine the 
consequences if the subject experiences hallucinations while driving, working 
with tools, or if he is placed in any situation where he could endanger the lives 
of others or harm himself. " 

It seems apparent, from the many articles on the subject, that most 
authorities will concede that serious damage is possible from the solvents in 
these glues. Therefore, it is not necessary to have a long list of substantiated 
reports, attesting to the damage from the inhalation of these solvents, to be 
convinced that it is possible. Because this possibility exists there is no need 
to wait until there is a bulk of evidence, like that which has been accumulated 
on drug addiction and alcoholism, to initiate programs to prevent this practice. 
However, we should not be satisfied with any one of the currently suggested 
methods of control. The glue manufacturers may not find an acceptable sub- 
stitute for the present ingredients. Legislation may fail in curtailing promis- 
cuous consumers (as it has in lowering the crime rate), or fail in stopping the 
want on sales of dangerous products (as it has in the illegal traffic of drugs). 
Abolition of this very useful type of product will not help because there are 
many other products such as gasoline, and cleaning fluids that could soon become 
a substitute. 



U.S. Navy Medical News Letter, Vol. 44, No. 5 



31 



Recommendations for control include: "Efforts aimed at correcting the 
underlying socio-economic and emotional disorder when they exist; a community 
approach to educate parents and children as to the potential risk of sniffing; 
making these glues and related substances less available on the open 'serve 
yourself shelves of stores; substituting less toxic organic solvents wherever 
possible; and adding special 'odor retardants' to some of these substances." 

The "coordinated citizens' approach" would seem most feasible at the 
present time. 



Intertrigo and Heat Rash 

Norman B. Kanof M D, Jour of Occup Med 6(7): 302-303, July 1964. 

Intertrigo occurs on skin surfaces so closely apposed that heat and moisture 
are retained, resulting in irritation and maceration. These conditions are 
met in the groin, on the inner aspect of full thighs, in the intergluteal cleft, in 
the axillae, beneath and between the breasts, between the toes, and between 
the fleshy folds that occur with an obese, pendulous abdomen, or a bulging neck. 

The skin becomes warm, red, and moist. Maceration and superficial 
abrasions may develop into severe denudation. The involved area is tender or 
even painful. Chemical alterations of the retained sweat and surface constituents 
produce a disagreeable odor. Bacteria and fungi flourish in this medium. 
These organisms contribute to the production and persistence of the eruption 
and sometimes result in frank secondary infection. In the anogenital folds, 
contamination from feces and urine adds to this process. 

The physical and mechanical factors are responsible for most instances 
of intertrigo, but this eruption may be a manifestation of another dermatosis. 
Seborrheic dermatitis and psoriasis may produce intertriginous lesions. Contact 
agents such as cosmetics or clothing, may produce eruptions in intertriginous 
sites. Antiperspirants and deodorants characteristically involve the skin of 
the vault of the axilla; clothing is more apt to produce its effect at the periphery. 
Infection with Candida albicans or with various species of Trichophyton proves 
to be the most important factor in some episodes of intertrigo. If these are 
resistant or recurrent, the possibility of an underlying diabetes should be 

investigated. 

The treatment of intertrigo involves separating the apposed skin surfaces, 
soothing the irritated tissues, and specifically correcting any supervening 
process or underlying dermatitis. 

Thin cloth bandages, homemade or commercially produced, should be 
placed between the skin surfaces. Proper evaporation and drying can be en- 
couraged by loose clothing. Pledgets (e. g. , cut-up dental rolls) between the 
toes and well-ventilated shoes are important when the feet are involved. Uplift 
bras are helpful for inframammary intertrigo. 



32 U. S. Navy Medical News Letter, Vol. 44, No. 5 

The areas should be gently and thoroughly cleansed and dried several 
times daily. Simple dusting powders reduce friction and absorb moisture. 
Lotions or creams containing corticosteroids are useful in the treatment 
of the more inflammatory intertrigos and of intertriginous psoriasis and 
seborrheic dermatitis. If monilia or bacteria infection is a prominent factor, 
iodochlorhydroxyquin, nystatin, or an antibiotic should be added. If Trichophyton 
is isolated from the lesion, Whitfield's ointment is usually effective, but 
occasionally oral griseofulvin is necessary. 

Heat Rash, or "prickly heat, " is more formally called miliaria rubra. 
The eruption consists of discrete or aggregated patches of red papules or 
papulovesicles on diffusely erythematous skin. There is usually considerable 
itching and discomfort. 

The sweat pore becomes occluded because of faulty keratinization, 
usually as a result of excessive, prolonged maceration. Sweat is retained in 
the sweat duct behind the point of occlusion and, when the duct dilates and 
ruptures, the sweat escapes into the epidermis to produce the clinical picture 
described above. 

Heat rash occurs anywhere except on the palms and soles. Usually, 
the face is spared. Sites of friction such as the belt line, the antecubital and 
popliteal fossae, and the upper trunk and abdomen are favored. The severity 
of the eruption and its symptoms are directly proportional to the stimulus 
placed on the damaged sweat apparatus by heat and exercise. 

Heat rash is frequently accompanied or complicated by such pyodermas 
as folliculitis, impetigo, and furunculosis. Heat rash may be a complication 
of a pre-existing dermatitis such as atopic dermatitis, contact dermatitis, and 
seborrheic dermatitis. 

The treatment of heat rash requires that the sweat apparatus be put at 
rest by minimizing the stimuli to sweating. In the absence of sweating, the 
lesions begin to resolve, the keratin plug is shed from the sweat pore and the 
normal relationship between the gland, the duct, and the skin surface is re- 
established. 

Air conditioning is the most effective method for resolving heat rash 
and preventing its formation. Even if air conditioning is available for only a 
portion of each day, the incidence of heat rash will be greatly diminished. Fans 
or other means of increasing air flow and evaporation are helpful in the absence 
of air conditioning. Occlusive protective garments should not be worn continu- 
ously; rest periods should be used for their removal for a time sufficient for 
cooling and drying of the skin. Intrinsic heat production may be minimized by 
reducing the work load. Systemic corticosteroids may be used to relieve the 
uncomfortable symptoms of severe heat rash while restoration of sweat gland 
function is taking place. 

Topical applications which unduly dry, macerate, or injure the skin 
(in such a way as to induce faulty keratinization) should be avoided. Most 
topical therapy accomplishes very little once the heat rash is present. 



U. S. Navy Medical News Letter, Vol. 44, No. 5 33 

Studies in Ecology of Coronary Heart Disease 

Lawrence E. Hinkle Jr. M D, et. al. , A rchives of Environmental Health, 
9(1): 14-20, July 1964. 

Cardiologists have long known that physical activity, changes in position, and 
certain bodily functions such as digestion and sleep may be associated with 
changes in the electrocardiographic complex. It has been postulated that some 
of the changes that occur under such circumstances are indicative of cardio- 
vascular disease, and that certain occupations or activities may accelerate or 
even cause coronary heart disease. Hence, it is important to have a more 
thorough understanding of the range of variation of the human electrocardiogram 
under a variety of ordinary conditions. The authors have taken advantage of 
recently developed methods for monitoring the electrocardiogram and are making 
a systematic effort to obtain a more exact gi.j;ture of the nature, the degree, 
and the frequency of the changes that occur Jfillar the conditions of daily life. 
Method. The phenomena that are b.SU[ described have been observed 
during the study of some 300 ambulatory, ostensibly healthy men and women 
between the ages of 20 and 60, of whom 200 were members of a randomly 
designated group of actively employed men in their 50' s. This study is still 
underway. Each subject is being observed throughout one day of carefully 
controlled and carefully timed activity in the author's laboratories. After a 
night's sleep in comfortable quarters provided by the writers, systematic 
recordings are being obtained under the following controlled conditions: 

1. With the Subject rested, fasting, and supine 

2. With the Subject in the left and right lateral decubitus, the knee-chest 
position, seated, and standing 

3. During the Valsalva maneuver 

4. During the Master's test 

5. During the ingestion of 500 cc of ice water, followed by 500 ccof 
hot coffee 

6. During three brief walks in the outside air of 175, 125, and 125 meters 
each (the ambient temperature has ranged from -4°C (25°F)to 24 C 
(75°F), depending on the season, with extremes from 12°C (10°F) to 
32°C (90°F)) 

7. During three hours of moderately challenging and anxiety-producing 
psychological tests and interviews 

8. During the ingestion of a high caloric meal of large bulk, followed 
by 360 cc (12 oz) of a carbonated beverage 

9. While walking up a flight of 13 stairs and over 125 meters of level 
ground immediately after this meal 

10. During the afternoon, after a day of continued sedentary activity to 
to the point of moderate fatigue. 
Additional, but less systematic, recordings have been obtained under a 
variety of other conditions throughout the day and during and after a large meal 



34 U. S, Navy Medical News Letter, Vol. 44, No. 5 

in the evening, as well as during sleep. Each step in the procedure is timed 
by stopwatch. A thorough medical history and cardiac diagnostic examination 
is carried out on each subject, as well as various laboratory investigations 
primarily concerned with fat transport. 

The ECG is monitored by means of the miniaturized battery-powered 
tape recorder, developed by Holter et al. This apparatus will record one lead 
of the ECG over a ten-hour period. The electrodes are placed over the fifth 
rib in the nipple line bilaterally. The lead used is bipolar and has the general 
characteristics of lead I, although, because of the position of the electrodes, 
it has the appearance of V. 

The data are analyzed by displaying the ECG complexes on an oscilloscope 
screen, superimposed on each other at 60 times "real-time. " This produces 
a "moving picture" of the ECG, in which ten hours of data are displayed in ten 
minutes. Any desired segment of the complex may be photographed, diagrammed, 
or written out at real-time as a standard ECG. The cardiac rate and rhythm 
are analyzed by displaying the RR intervals as vertical bars on a calibrated 
oscilloscope screen. 

Preliminary Findings . Although the majority of the young people thus 
far observed have relatively stable complexes, nearly all have displayed a loss 
of amplitude of the T -wave upon arising from a sitting position, or on the 
Valsalva maneuver. The ingestion of hot and cold fluids has had little effect 
upon this lead of the ECG. The Master's test shortens the QT time and usually 
causes the T -wave to lose amplitude as the heart rate increases. Walking 
175 meters in the outdoor air has an effectas great as that of the Master's test. 
As a large meal is ingested, the T -wave loses amplitude and the rate increases. 
Walking up a flight of stairs after the meal accentuates this effect. Nearlyall 
young people have shown a moderate phasic variation of heart rate with respira- 
tion. In the afternoon after a large meal, the heart rate is consistently 10 to 
20 beats per minute greater than in the morning. 

Approximately one third of the young men thus far observed have had 
more labile complexes. When they are in the standing position or performing 
the Valsalva maneuver, their T-waves may become notched or inverted. On 
the Master 's test, the ST segments may become slightly depressed. Walking 
175 meters in the outdoor air has a similar effect. While they are ingesting a 
large meal, their T-wave may become flattened, notched, or inverted. When 
they walk up a flight of stairs after the meal, their ST segments may become 
noticeably lower, and sometimes depressed, and this may persist for a short 
while. An equal or greater proportion of healthy young women appear to have 
unstable complexes. Their T-waves invert on standing or on the Valsalva 
maneuver. They show a sharp rise in heart rate and slight depression of the 
ST segment on the Master's test. Similar or even more marked changes occur 
when they ingest a large meal and then walk up a flight of stairs. 

In some subjects, the electrocardiographic complex undergoes a regular 
evolution during the course of a day. In the morning, with the subject rested 
and moderately active, the complex has a "healthy, " "normal" appearance. In 



U. S. Navy Medical News Letter, Vol. 44, No. 5 35 

the afternoon, after a busy day, the T -wave is lower and tends to become 
notched or inverted. As the tired subject ingests a large dinner, the T-wave 
may invert entirely and the ST segment may become depressed. These changes 
persist during the evening. However, after 20 minutes of restful sleep, the 
T-wave is again upright, and after six hours of sleep, the complexhas resumed 
its healthy, normal appearance. 

In men in their 30's and 40's, electrocardiographic changes with position, 
diet, and activity have seemed to be more pronounced and persistent then they 
are in younger men. During a large meal, the T-wave may become quite flat 
and notched. A pronounced ST sag may develop after the meal and persist 
during the afternoon. 

These effects seem to be even greater and more persistent among older 
men. For example, a man of 56, with a blood pressure of 160/90 and a history 
of some "atypical chest pain" in the past, had only slight changes in a standard 
exercise test. Walking 175 meters in the outdoor air producedan alarming sag 
in his ST segment, but no symptoms. After a large meal and climbing a flight 
of stairs, he exhibited a "distinctly pathological" ECG. This persisted all 
afternoon, but at no time did he have any symptoms or appear to be in any way 
distressed. Phenomena such as this have been observed repeatedly. 

Atrial premature contractions have been noted at all ages, but they are 
less common than ventricular premature contractions. They seem to show a 
distinct association with pulmonary disease. 

Ventricular premature contractions are very common. Most men in 
their 50's have been found to have from one to five ventricular premature 
contractions per hour, and some have as many as 400 per hour. They often 
increase with anxiety, and after a large meal, they may become very frequent 
and appear in pairs or bursts. 

Not infrequently, the authors have noticed striking electrocardiographic 
changes in ostensibly healthy men in their 50 's. Such a man may have no 
history of cardiovascular disease. His standard ECG is normal, and after a 
careful examination by a cardiologist, it has been decided that he has no 
clinical evidence of cardiac disease. Yet, a short walk in the outside air 
produces a noticeable ST segment depression. Psychological tests bring forth 
bursts of ventricular premature contractions, many of them followed by T-wave 
inversion. A large meal greatly accentuates these changes, which persist 
throughout the afternoon. Yet the subject remains asymptomatic throughout 
all of this. 

Striking changes in intraventricular conduction have also been recorded 
with considerable frequency in asymptomatic middle-aged men. For example, 
an asymptomatic man, whose only known cardiovascular disorder was a modest 
grade of hypertension, displayed alternately right bundle branch block, left 
bundle branch block, and normal intraventricular conduction. The normal 
intraventricular conduction was usually associated with two to one atrioventricu- 
lar blockanda more rapidatrial rate. Throughout most of the day, this alternated 
with slower sinus rhythm accompanied by right bundle branch block and normal 
atrioventricular conduction. 



36 U. S. Navy Medical News Letter, Vol. 44, No. 5 

A number of men who have developed anginal pain on the Master's test, 
on walking 175 meters outdoors, and after a large meal, have had electrocardio- 
graphic changes less pronounced than those of many men who remained asymp- 
tomatic throughout the day. 

Some men, whose electrocardiograms show ST segment depressions 
and inverted T-waves in the morning, have developed upright T-waves, often 
without segment depression, after exercise or after a large meal. 

During follow-up studies, some men who were observed to have abnormal 
ECG's have later developed myocardial infarction. 

A significant proportion of men in this age group have had electrocardio- 
graphic complexes as stable as those of young men in their 20's. On the 
Master's test, on walking 175 meters in the open air, after. a large meal, and 
with fatigue they have developed no significant change in the complex and no 
evidence of disturbed conduction or of arrhythmia. Yet, two of these men 
have died suddenly with the clinical syndrome of acute myocardial infarction 
within several months after the authors studied them. 

Comment. The evidence to date indicates that changes in the ST seg- 
ment and T-wave vectors occur so frequently in people of all ages and both 
sexes, in association with ordinary activities and common physiologic states, 
that the writers believe it is hazardous to assume that they necessarily indicate 
the presence of a pathological process. 

There is a strong suggestion that some people with unreactive and quite 
stable electrocardiographic patterns may be at least as susceptible to acute 
myocardial infarction or to sudden death as those with more labile patterns. 
On the other hand, the finding that asymptomatic men in their 50' s, most of 
whom presumably have extensive coronary atherosclerosis, may exhibit pro- 
nounced arrhythmias and changes in intraventricular conduction during periods 
of anxiety, while ingesting a meal, or while engaging in ordinary activity, 
suggests that rather trivial events might possibly initiate serious episodes of 
arrhythmia, or even ventricular fibrillation and death, in people with damaged 
or partly impaired hearts. 

jJU *i!»» J£ «jg *** jfe 

Hazards May Lurk in Your Hobby 
D. E. Bell MD, Occup Hlth Bulletin, Vol. 19, No. 4, 1964. 

"Tis to create and in creating live." There in Lord Byron's words lies the 
reason, the purpose, even the need for a hobby. Whether it be the modeling 
of a spacecraft, or the building of a strong light boat, the hobbyist has a sense 
of accomplishment and fulfillment of his need for creative work. 

Today, there is greater need than ever for creative expression, as 
computers and other mechanized giants usurp the work of brain and hand. 

Because these same machines have freed men's hands andliberatedtheir 



U.S. Navy Medical News Letter, Vol. 44, No. 5 37 

minds, they now have more leisure time. Compare the hobbyist of grandfather's 
time with the hobbyist of today. Grandfather probably worked 60 hours or more 
a week, 52 weeks a year for an annual income of slightly more than $1, 000. 
His grandson works only 40 hours a week, has a two- weeks paid vacation and 
earns between $3, 000 and $4, 000 a year. He is therefore in a favored position 
to engage in a hobby. And he finds countless things to do and make; awaiting 
his ingenuity is an almost bewildering array of tools, chemicals, resins, waxes, 
glues and other substances to use as he chooses. 

Free from the nagging care and hurly burly of the day's work, he may 
spend many happy hours absorbed in his chosen pursuit. Free from the watchful 
eye of the foreman and safety supervisor, the gleaming teeth of his circular 
electric saw may whirl through a 2" x 4" pine board and a finger carelessly 
left in the path of the saw's advance. Mist of a garden insecticide from his 
spray gun may fall alike on his apples and himself; glues, waxes and plastic 
paints, may coat part of his skin as well as his boat. Too late, he realizes 
from the stub of a finger, the irritating bright red rash on his arm or the 
nausea and dizziness experienced after spraying his apple trees that for him, 
the careless worker, some hobbies are not without their hidden hazards. 

Sooner or later experience teaches the heedless hobbyist or the careless 
Mr. Fix-it that some spare-time jobs are like uncharted seas where lurk many 
a reef: unfamiliarity with tools and materials, lack of knowledge of their use 
and properties, lack of adequate precautions, absence of supervision. 

The unwary hobbyist may run afoul of these hidden reefs because he 
tends to choose a pastime unrelated to his paid employment. The operator of 
a lathe may be quite unfamiliar with the potential hazards of certain pesticides, 
or the dangers inherent in commonly- used substances like benzene and carbon 
tetrachloride. Likewise, a chemist may be unprepared for the speedand power 
of his electrically-driven drill-press. 

Tools . Power tools need no "hidden persuaders" to sell them. Already 
the would-be purchaser covets them because of the amazing variety and diversity 
in their use. If he uses them carefully, he is likely to keep all ten fingers 
intact. But concerned with getting on with the job, the handyman may feel 
pressed for time and may not pause to read warning labels or directions for 
use. Crushed and amputated finger ends attest to his all too common heedlessness. 

Potentially Dangerous Substances . Just as a knowledge of his tools is 
important to the safety of the hobbyist, so, too, is a knowledge of the chemicals, 
glues, waxes, resins and other materials he uses. 

Epoxy Resins . Unfamiliar though epoxy resins are to a do-it-yourselfer, 
he may try them on the boat he is building. Although useful, these "wonder 
glues" require careful handling because of their potentially toxic properties. 
Their bonding properties make them desirable if not indispensable for certain 
applications. Unfortunately, they possess toxic properties which, at present, 
seem to be inseparable from their desirable ones. In fact, the very charac- 
teristics that make them potentially hazardous the high degree of chemical 

reactivity of the basic ingredients are largely responsible for their great 

strength as bonding agents. 



38 U. S. Navy Medical News Letter, Vol. 44, No. 5 

Dermatitis is the most common effect experienced from exposure to 
epoxy resins, though ill effects from inhalation of fumes of plastic can also 
occur. Skin contact should therefore be avoided with the resins and hardeners 
and they should be applied only in very well -ventilated rooms. 

Pesticides. Like the untrained user of epoxy resins, the backyard 
gardener is less likely to know the potential hazards of certain compounds than 
the farmer or orchardist. Not only may he have no hesitation in using pesti- 
cides on his flower garden or apple trees, but he may do so without reading 
the label. "Unintentionally he does more harm to himself andhis neighbor than 
the farmer who is aware of the hazards", said Dr. Henry Hurtig of the Depart- 
ment of Agriculture, Ottawa. 

"And no farmer would likely use four pounds of a pesticide when direc- 
tions call for half a pound — it costs too much, and he knows his crops might 
have a residue exceeding legal limits", said Dr. Robert White-Stevens of the 
American Cyanamid Company of Princeton, N. J. 

But it is not only back-yard gardeners whose health may be jeopardized 
by the misuse of pesticides. A threat to health exists within the home through 
their careless or excessive use. A pathologist's report lists the death of a 
ten-year old girl as "aplastic anemia probably due to DDT". According to the 
report the girl's mother had used DDT around the house as an insecticide 
"liberally and repeatedly. " The insecticide's solvent may have been a con- 
tributing cause of death, but specific information on the nature of the solvent 
in the DDT used was not available. 

Carbon Tetrachloride. Unlike certain pesticides which are of compar- 
atively low toxicity, carbon tetrachloride is highly toxic ten times more 

poisonous than carbon monoxide. Unfortunately, because of its excellent 
solvent properties and non-flammability, carbon tetrachloride is commonly 
used in the home as a stain remover and as a cleaner for rugs, upholstery 
and tools,. Never, under any circumstance, should this extremely dangerous 
compound be used in the home workshop or for domestic purposes. Carbon 
tetrachloride's lethal power is increased if the person using it has recently 
had a drink containing alcohol or drinks an alcoholic beverage while using this 
solvent in a poorly-ventilated place. A man is known to have died from carbon 
tetrachloride poisoning while drinking a quart of beer as he cleaned his rug. 

What to Do, What safeguards are there for those who want to find 
self-expression in creative work outside their employment? Briefly they are: 
know the potential for harm of the material or equipment you are using. Read 
and apply to your work the directions for use on the label. And remember the 
labels mean exactly what they say. If, for instance, the label states, "Use 
only in a well -ventilated area"; do not use in a room where there is little 
or no ventilation. Disregard of the warning label can lead to illness or death; 
as cases in scientific and medical literature silently testify. 



U. S. Navy Medical News Letter, Vol. 44, No. 5 39 




RESERVE ^15^ SECTION 



Farewell Remarks by RADM F. J. Becton, USN * 

ROA IS DESERVING OF YOUR SUPPORT In outlining the objectives of the 

Naval Reserve for Fiscal Year 1965, I stated that the current Selected Reserve 
manpower ceiling of 126,000 in drill pay status presented us with a challenge in 
our efforts to provide our country with a Naval Reserve of the highest quality. 
We tried unsuccessfully to have this ceiling raised, for we have maintained that 
a maximum drill pay strength of 126, 000 is not realistic. For this reason, I 
was delighted to see that the House of Representatives has included intheappro- 
priations bill for Fiscal Year 1965, an increase to 132, 000 in the personnel 
ceiling of our drill pay Reserve including provisions for obtaining the necessary 
funds to support this increase. Largely responsible for this legislation in our 
behalf has been the Reserve Officers' Association. This Association is chartered 
by the Congress with a mission to maintain a strong national defense posture. 
In view of its Congressional charter, the National Staff of the Association appears 
before the Congressional committees on matters of National Defense. They are 
highly respectedby the Congress, alert to our needs, and have a splendid record 
of more than forty years of accomplishments in behalf of our nation's Armed 
Forces, both Regular and Reserve. 

In nearly three years association with the Naval Reserve, Ihave had the 
opportunity of meeting hundreds of fine Reserve officers, many of whom realize 
the benefits to be derivedthrough active membership inROA. Through member- 
ship in ROA, one has a voice in making possible much of today's legislation in 
support of military policies for the United States that provide adequate national 
security. ROA's national leaders spend long hours at work in our Nation's 
capitol where ROA-sponsored proposals have successfully passed the legislative 
maze of subcommittees, committees, House and Senate. 

The fact that ROA represents andlooks after the interests of all branches 
of the Armed Forces adds to the weight of this organization's testimony to the 
Congress and in so doing, increases ROA's effectiveness in support of the Navy. 
At the recent ROA convention in Portland, ^Oregon, I was impressed with the 
relatively high percentage of Coast Guard Reserve officers who actively partici- 
pate in ROA affairs. Membership in ROA can be equally beneficial to all Naval 
Reserve officers. 

For the past 34 months it has been my privilege to serve as Commander 
Naval Reserve Training Command a most interesting and challenging assignment 
which has reaffirmed my convictions as to the wisdom of maintaining a strong 
and well trained Naval Reserve. Too often, our Naval Reserve is regarded as 
a Force which, in time of war or national crisis, will voluntarily spring from 
the rank and file of the communities throughout this great nation. This was the 
case in World War II when from only 285, 000 officers and men just prior to the 



40 



U. S. Navy Medical News Letter, Vol. 44, No. 5 



war, our Navy expanded to almost three -and -one -half million men and women 
on VJ- Day in 1945. Eighty- seven per cent of these were Reserves. Theinterest 
I developed in the Naval Reserve during the war has remained with me ever since. 

As I leave this Command to take over my new assignment as Naval Inspec- 
tor General, I do so with the utmost pride and sincere appreciation. lam pro- 
foundly proud that our fine Selected Reserve is today much stronger and in a 
higher state of readines s than in recent years . The preceding Fiscal Year marked 
the first time in recent Naval Reserve history that the Selected Reserve has 
attained the enlisted pay strength authorized by the Department of Defense. 

Upon reporting to Omaha as Commander Naval Reserve Training Command 
in October 1961, the Reserve crews of our forty Naval Reserve destroyers and 
destroyer escorts of our Anti -Submarine Warfare program had been recalledto 
active duty incident to the tensions which had arisen in Berlin and Southeast Asia. 
Although the officers and men of these ships performed superbly during the 
call-up, when they returned in August 1962, many did not remain with the Reserve 
crews. Today, I am proud to report that these ASW ships are now more fully 
manned and in a better material condition than they were in 1961. The Reserve 
crews of these ships have grown from a low of 16 percent nation-wide average 
personnel allowance immediately following their release from active duty to 
over 93 per cent at present. 

The past year has been marked by improved quality and increased 
readiness within all of our Selected Reserve programs. We are providing our 
country with a well trained and responsive Naval Reserve. Had it not been for 
cooperation and dedicated effort on the part of officers and enlisted personnel 
at all levels of command, these accomplishments would not have been possible. 
To each and all of you, I offer my sincere thanks and a hearty "Well Done. " 
It has been a pleasure serving as your Commander. 

^Rendered on the occasion of Admiral Becton's detachment as Commander, 
Naval Reserve Training Command, Omaha, Nebraska. 



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